If the Patient Protection and Affordable Care Act (PPACA) was theatre, it would have to be written by Shakespeare, strictly for the sheer range of human emotion and vitriol it has evoked. From the time it was conceived to the most recent State of the Union, the PPACA has consumed the national consciousness and added further polarity to arguably the most partisan political climate in the last century. And, just like many of Shakespeare’s characters, the legislation is a mixed bag, balancing the fact that it is the most sweeping social reform since The Great Society and will expand coverage to thirty million people, with the hubristic assumption that young people will actually sign up and allow it to succeed. But while some of Shakespeare’s greatest ironies were played out with an audience that knew more than the characters, Obamacare has reversed that dramatic irony and been played for an audience that refuses to open its eyes to more than half the story.
At its most bare-bones, the Affordable Care Act has two components: access to care and the care itself. While everybody has spent the last four years literally screaming at each other over the access bit, there has been virtually no public discussion regarding what the legislation will mean for the quality, composition and equity of care. And yet in a country that is not just riddled with crippling healthcare costs, but also far-below average health outcomes this latter component is every bit as important. There is no denying that costs and quality of care are inextricably linked and so our focus as the society that will critique, rework and ultimately live through this legislation must take both facets into consideration when we discuss the relative merits of Obamacare.
The most talked about way that the PPACA changes care is by presenting an immediate incentive shift in hospital billing practices. Whereas before the act, hospitals had an incentive for keeping you sick where they could bill your insurance for every time you had to be readmitted to the hospital, the PPACA immediately changed that. For the first time, hospitals had to eat the costs if a patient was readmitted within thirty days presenting with the same conditions. As Dr. Singh at Mount Sinai says, “Suddenly, doctors said, ‘We’d better build a system to take care of people for thirty-one days.’” But, as Dr. Singh also adds, “What about the rest of the year? Why not make a system that takes care of people for 365 days, and not have them just come in and out of the hospital?”
This, I think, is the most interesting part of the Affordable Care Act, as it creates the space for hospitals to experiment with the most effective ways to keep people healthy for the longterm. Over the three plus years since the bill was passed we have seen a seismic increase in the number of federally funded Medicare accountable care organizations that will basically operate on an incentive-based system to keep as many people healthy for as long as possible. Essentially what an accountable care organization does is give a hospital or any other provider with a large enough patient population accountability for the total health care costs of the patients they see, and if they are able to cut down on those costs then they get to share in the savings with the insurance provider (in this case Medicare, but also Medicaid in the near future). This innovative model provides incentives for providers not only to give patients the best quality of care when they show up to the doctor’s office or emergency room, but also to start experimenting with ways to keep patients from needing care in the first place. Ultimately, it will always be less expensive for hospitals to help their patients eat more healthily or exercise more or adhere to their medications, than it will be for them to treat diabetes or hypertension or aggravated medical conditions when they present.
In February, 2010, just a month before the Affordable Care Act was passed, the University of Wisconsin Population Health Institute released a working paper that weighted the effect that various inputs had on health outcomes. Taking into consideration health behaviors (i.e. smoking, diet, exercise), social determinants (i.e. level of education, income), physical environment (i.e. pollution), and clinical care, the study claimed that social determinants contributed forty percent to a person’s length and quality of life, health behaviors thirty percent, clinical care twenty percent, and physical environment ten percent. The implications of the study are tremendous, as it put a number to what many of us in health care have been claiming for years, that what you do out of the hospital is significantly more important than what happens in it. And with epidemics of hypertension, diabetes, obesity and asthma all tied to health behaviors and social determinants, the need for community-based care outside of a hospital becomes increasingly important.
It is this changing composition and quality of care that will be the most interesting part of the Affordable Care Act moving forward. With the kinks in the website figured out and recently reported skyrocketing rates of people buying on the exchange, the access component will most likely work itself out, albeit with plenty of hiccups along the way. The real question then will be whether or not the experiments within this new incentives-for-care world will be successful, whether we can expand the ingenuity we apply to diagnosis and treatment, to community-based models that keep people healthy before they become burdened by disease. It is that much less publicized and much more important part of the act that will ultimately be the deciding factor in its success. So while Congress may keep fighting to repeal Obamacare, the rest of us would be better served focusing our energies in this sphere and trying to move this country in a healthier direction.